Contacting Us

We are very excited to have the new site up and running.  However, we had a little technical problem on Saturday November 14th.  If you used our contact page to send us a note, our hosting service never forwarded it to us unfortunately.  So if you tried to connect to us that day, please try again.  The same page will work fine now.  We have corrected the problem.  We appreciate your understanding.  Thanks!

- Drs. Presant and Kempe-Mehl

Your Brief Guide to Deep Brain Stimulation

With the recent media attention on Deep Brian Stimulation, more patients are questioning whether undergoing this procedure is something that will make a positive difference in their lives.  Here is your quick guide to DBS. 

What is Deep Brain Stimulation?

Deep Brian Stimulation (DBS) is a surgical procedure approved in the United States for over 15 years for treatment of Parkinson’s Disease (PD), Essential Tremor (ET), and Dystonia.  It is used specifically for the treatment of tremor, bradykinesia (slowness), rigidity (stiffness) and dyskinesia (levodopa induced abnormal/extra movements) in PD.  It is used to stop the tremor in ET patients.  The procedure itself involves a small lead that is inserted into the brain through a small hole in the skull.  Usually during this procedure the patient will remain awake as the clinical effects of this stimulation can be seen immediately in the operating room when the correct location for the lead has been reached.  The lead is positioned in one of two places for PD, the subthalamic nucleus (STN) or the globus pallidus internus (GPi), and for ET the lead is placed in the thalamus; usually GPi is used for the treatment of dystonia.  These different areas are nuclei in the brain that are thought to contribute to the pathology of each of these diseases.  While we know that the electrical stimulation that these leads deliver are helpful, we do not know the exact mechanism of how DBS works.  It is considered to be a “pacemaker” for the brain.  The exact location of the lead placement is decided upon prior to the surgery in conjunction with the neurosurgeon, the movement disorders specialist and the patient. 

After the lead has been inserted into the brain a wire is tunneled under the skin from the head to the chest where it is attached to a battery (IPG).  This battery will need to be replaced on average every 3-5 years.  Once implanted, it looks similar to a pacemaker battery. 

How soon do I see the effects?

Usually the DBS system will not actually be “turned on” or programmed until about 2-4 weeks after the initial brain surgery.  This is partly to wait for the reduction of swelling in the brain from the surgery in order to get a more accurate assessment at the programming session with your neurologist.  Sometimes we see a dramatic improvement in the few weeks immediately after surgery and then symptoms will slowly return.  This, again, has to do with the swelling in the brain and is from the actual lead placement itself.

Is deep brain stimulation right for me?

The answer to this question lies in the specifics of your own clinical picture.  To understand this, you must work closely with your movement disorders specialist.  In general, for PD, DBS only really helps symptoms such as bradykinesia, rigidity and dyskinesia.  We do not implant someone with DBS if gait and balance are main issues or if there are significant cognitive problems.  For this reason, everyone who is a DBS candidate must undergo neuropsychological testing prior to the surgery.  Neuropsychological testing is a 3-4 hour long process involving questions and activities that test many different domains of the brain.    It also assesses depression and anxiety to help us fully understand your full cognitive profile before putting you through brain surgery.  In the past there has been some evidence that DBS could potentially worsen gait/balance and/or cognition. 

For essential tremor, DBS becomes an option when you have tried multiple medications and either have no benefit from those medications or cannot continue to take more due to side effects.  Although the cognitive issues are certainly less with ET, most ET patients will also undergo neuropsychological testing prior to the surgery. 

Considering brain surgery can be scary and many people consider DBS a “last resort” therapy for PD, however, it really is not that.  You can pass a point in your PD where you are no longer a candidate for surgery due to gait/balance issues and cognitive issues as discussed above.  For most patients, DBS does make a huge difference in their lives: in the ability to move, in the reduction of dyskinesias and sometimes in the reduction of medications.  This surgery should be done at a large center by a neurosurgeon who is trained in this type of surgery.  If you are interested in DBS you should discuss it with your doctor earlier rather than later. 

 

How can I learn more?

You can check out NatGeo’s recent live DBS surgery at: http://channel.nationalgeographic.com/brain-surgery-live-with-mental-floss/videos/dbs-explained/

If you would like to learn more information about DBS, please attend the DBS Evening put together by PASB and sponsored by Medtronic on Thursday January 21, 2016 from 5:30-7:30pm at St. Andrew’s Church where you will be able to ask questions of patients who have had the procedure.  Dr. Kempe-Mehl and I will also be available to answer questions regarding DBS.  We would love to see you there!!!

-Dr. Erin Presant

“…And what do you do for exercise?”

“…And what do you do for exercise?” is not always a popular question with a new patient in clinic. 

 

But for movement disorder doctors, reviewing patients’ exercise routines is becoming the standard of care, and for good reason. When I see patients with Parkinson’s disease, I especially emphasize the importance of regular physical exercise. Taking on this challenge is no easy feat for the average person – having a regular exercise routine requires a level of accountability that doesn’t come naturally for most of us. Certainly there are tips and tricks that can help with this lifestyle change. Perhaps the most important one is choosing a form of exercise you enjoy, whether this be walking, riding a stationary bike, swimming, yoga, tai chi, dance classes, boxing, physical therapy, etc. Whether you are able to run for long distances, or are limited to exercising in a seated position, it is critical that the exercise be intense and long enough to raise your heart rate and make you breathe more heavily. It is important to be consistent with whichever form of exercise you choose, and to build it into your schedule. For example, those enrolled in formal classes or programs have been shown to demonstrate the most significant gains in motor function. Exercising with a friend or partner often helps people keep a regular routine as well, as workout buddies can keep one another motivated and engaged. And of course, it is important to know your limits, and to exercise in settings that are safe, and that do not introduce the possibility for falls or injuries. 

 

For many years, we have known that the improved mobility that results from regular physical activity allows for more physical independence, decreases the risk of falls, and allows for an improved overall sense of well-being. In truth, all the new research showing the potential benefits of exercise suggests that it is important for all of us to be exercising. Regular cardiovascular exercise does not only potentially slow the progression of Parkinson’s disease, but may also delay/prevent the onset of dementia, and allow for fewer changes in the brain caused by aging. Personally, I have found this literature so convincing, it has changed how our family structures our own exercise routines. But while the data suggests that we should all be getting regular physical exercise, the stakes may be higher when you have a disease like Parkinson’s disease, in which you are losing a certain type of neuron (dopamine neurons) faster than the average person. 

 

In my own practice, I prioritize this conversation, “What do you do for exercise?” during clinic visits, and even at the time of a new diagnosis with Parkinson’s disease. This is because physical activity is the only intervention (so far) that has demonstrated, in animal models, that it may potentially slow the course of neurodegenerative diseases, such as Parkinson’s disease.  In other words, we have little to offer that can “modify disease progression.” For example, large studies looking at interventions like creatine, inosine, exenadite, coenzyme Q-10, etc. have failed to support the use of these substances in slowing the progression of disease. But the mounting evidence that exercise may affect the course of the disease is very exciting, both to patients and providers. 

 

The National Parkinson Foundation is currently performing the largest clinical study of Parkinson’s disease that has ever been conducted, called the Parkinson’s Outcomes Project. Among other questions being investigated, this project is also evaluating the importance of regular exercise. In fact, there are so many basic science studies being produced by research groups from all over the world, that it would be impossible to summarize this growing field in this short entry. However, at this year’s International Parkinson and Movement Disorder Society’s 19th International Congress, researchers emphasized that exercise not only improves the motor symptoms in Parkinson’s disease (stiffness, slowness, rigidity, balance, flexibility, coordination, etc.), but that it also promotes independence, improves quality of life (across all different stages of disease), improves sleep, improves mood (depression, anxiety, apathy), and delays cognitive changes; more specifically, exercise decreases the risk of Parkinson’s disease dementia, as well as Alzheimer’s dementia and vascular dementia (adapted from presentations by Drs. W. Poewe, A. Storch, T. Simuni, T. Mestre, & D.J. Surmeier). 

 

As the importance of cardiovascular exercise started to receive new recognition during my training, I was always taught that exercise might be protective from a “vascular” standpoint; regular cardiovascular exercise keeps the tiny blood vessels supplying the neurons of the brain healthier for longer (much like regular physical exercise is good for the arteries supplying the blood to your heart). But new research looking at exercise-induced neuroplasticity in animal models is broadening this horizon, and also suggesting that for patients who exercise, brain cells may use dopamine more efficiently. Personally, I’ll be looking forward to learning more from Dr. Giselle Petzinger of University of Southern California, who recently received an Innovative Research Grant from the National Parkinson Foundation for her research studying the biology of exercise at the cellular level. Her group’s exciting work proposes the hopeful message that the neuroplasticity created from exercise in patients with Parkinson’s disease may help combat the neurodegenerative effects inherent to the disease. Dr. Petzinger will be speaking at this year’s annual Parkinson’s Association of Santa Barbara (PASB) symposium on April 16, 2016 (http://www.mypasb.org for further details). See you there! 

- Dr. Sarah Kempe-Mehl

Introduction

This is going to be our new spot to give you all the information that is news! Here you will find articles, information about current developments in treatments, our own research and insights we want to share with you.  Check in often.  We look forward to sharing!

- Dr. Erin Presant